STUDENT ACCESSIBILITY AND ACCOMMODATION
UNIVERSITY OF PUGET SOUND
Medical Documentation for Housing Issues Medical Single
STUDENT ACCESSIBILITY AND ACCOMMODATION
1500 N. Warner St. #1096, Tacoma, WA 98416-1096, T: 253.879.3395 or 3399, F: 253.879.3786
Email: saa@pugetsound.edu
Student’s Name:
Student DOB:
ID#________________________Telephone_____________________________________ Date _________________
Student Accessibility and Accommodation complies with federal and state disability laws that prohibit discrimination and require that
universities ensure equal access for qualified persons with disabilities to educational programs, services and activities. Please
complete the form below to assist D.S. in determining appropriate and reasonable disability accommodations. Additional
documentation may be required.
To be completed by student’s treating professional, NOT by a family member. All items are required. Please print legibly.
Complete Diagnosis:
Explain how symptoms functionally prohibit student from
living with a roommate:
______________________
Date of Diagnosis:
Date of last visit for this condition:
__________________________________________________
Procedures/assessments used to diagnose this student’s
condition:
Severity of the condition:
Mild
Moderate
Your specific recommendation that it is your professional
opinion that an accommodation of a single room placement
is essential for the student’s physical/mental health; ______
Severe
Student is compliant with medical treatment for this
condition: Rarely Sometimes Often Unknown
Does this student take prescription medication for this
condition? Yes ___ No ___ If yes, which medications? Please
note any side effects:
_____________________
Has this student been treated in an emergency room for this
condition within the last year? Yes ___ No ___
Has this student received in-patient treatment for this
condition within the last year? Yes ___ No ___
Nature of symptoms and limitations: __________________
_________________________________________________
_________________________________________________
How often does this student experience the above
limitation(s)? Rarely Occasionally Frequently
Affix business card or apply business stamp within this box
[Type text]
Describe your follow-up plan for your patient:
Recommended accommodation (must be clearly linked to
functional limitations):
__________________________________________________
__________________________________________________
__________________________________________________
Treating Professional‘s
Signature _________________________________________
Professional’s Name:
Address:
License/Cert. #:
Specialty:
Phone:
State:
Fax: